CASE REPORTS

Transcatheter closure of recurrent aorticpseudoaneurysm previously treated by Amplatzeroccluder deviceJamal Hussain, MD,a Robert Strumpf, MD,b Aslan Ghandforoush, DO,c Grayson Wheatley, MD,b andJohn Sutherland, MD,b Phoenix, Ariz

Thoracic pseudoaneurysms are a rare variety of aortic disorders that are potentially fatal. Traditionally, these are treatedsurgically. False aneurysms are usually a late complication of a previous surgical procedure. Surgical management is oftencomplicated by poor outcomes with high morbidity and mortality. We report a patient with recurrence of an aorticpseudoaneurysm after closure with an Amplatzer (AGA Medical Corp, Plymouth, NH) septal occluder that was

successfully treated with a second Amplatzer device. ( J Vasc Surg 2010;52:196-8.)

Thoracic pseudoaneurysms are a rare variety of aorticdisorders, and although mostly asymptomatic, they repre-sent a potentially fatal condition. Traditionally, these aretreated surgically. False aneurysms of the aorta are usually alate complication of previous surgical procedures, especiallyreconstructive surgery, trauma, and rarely, infection. Sur-gical management is often complicated by poor outcomeswith high morbidity and mortality.1 Our center and othershave previously published case series of transcatheter clo-sure of aortic pseudoaneurysms with an Amplatzer device(AGA Medical Corp, Plymouth, NH).2,3 We report a pa-tient with recurrence of aortic pseudoaneurysm after closurewith an Amplatzer septal occluder that was successfully treatedwith a second Amplatzer device.

CASE REPORT

A 69-year-old man had a history of traumatic aortic aneurysmand underwent a repair of Stanford type A for aortic dissection inJanuary 2007. An aortic pseudoaneurysm subsequently developedat the proximal suture anastomotic site after a fall. He underwentsuccessful endovascular repair of the expanding pseudoaneurysmwith a 12-mm Amplatzer cribriform septal occluder device inJanuary 2008.

A follow-up computed tomography (CT) scan in November2008 showed a recurrence of the partially thrombosed pseudoan-

From the Arizona Heart Hospital,a Arizona Heart Institute,b and PhoenixVA Medical Center.c

Competition of interest: none.Correspondence: Jamal Hussain, MD, Arizona Heart Hospital, 1930 E

Thomas Rd, Phoenix, AZ 85016 (e-mail: xnorbeht@yahoo.com).The editors and reviewers of this article have no relevant financial relation-

ships to disclose per the JVS policy that requires reviewers to declinereview of any manuscript for which they may have a competition ofinterest.

0741-5214/$36.00Copyright © 2010 by the Society for Vascular Surgery.

doi:10.1016/j.jvs.2010.02.005

196

eurysm. The entry point was proximal to the previously deployedAmplatzer device. The maximum aortic diameter was 7.5 � 8.8mm, and a decision was made to consider transcatheter treatment(Fig 1) owing to the patient’s previous open repair that led topseudoaneurysm development that was treated percutaneously.The recurrent pseudoaneurysm appeared to be amenable to per-cutaneous treatment. Options were discussed with the patient, andtranscatheter treatment was chosen.

The procedure was performed under general anesthesia.Right femoral access was obtained with a 9F introducer sheath.A transesophageal echocardiogram (TEE) probe was inserted toidentify the defect along the proximal suture lines. TEE andintravascular ultrasound (IVUS) were used during procedure tobetter guide the procedure and because this is a somewhatinnovative approach and fluoroscopy does not provide anatomicdetails of the structures.

An ascending aortic angiography performed with a pigtailcatheter showed a subtle takeoff of the defect, and multiple angio-grams were performed to best illustrate the angle of the takeoff ofthe defect (Fig 2, A). The catheter was exchanged for a stiffLunderquist wire (Cook Medical, Bloomington, Ind), and IVUSwith a Volcano catheter (Boston Scientific, Natick, Mass) of theascending aorta identified the lesion to be medial and proximal tothe prior Amplatzer device.

The defect was cannulated from the right femoral artery with4F Judkin catheters. An angiogram of the pseudoaneurysm sac wasperformed. Then the right Judkin catheter was exchanged withstiff Supracore wire (Abbott Vascular, Abbott Park, Ill), and ashuttle sheath was advanced. We encountered resistance whilecrossing the lesion with the shuttle sheath; therefore, the shuttlesheath was removed and balloon angioplasty of the defect wasperformed with a 2- � 6-mm balloon. We decided to use the 6-mmballoon after resistance was encountered when the shuttle sheathwas advanced through the defect. We were then able to advance

the shuttle sheath into the cavity.

JOURNAL OF VASCULAR SURGERYVolume 52, Number 1 Hussain et al 197

The Supracore wire was withdrawn and an Amplatzer cribri-form 18-mm septal occluder was advanced and deployed. Anangiogram of the ascending aorta with a pigtail catheter was

Fig. 1. Recurrence of the pseudoaneurysm above the previousAmplatzer device is shown in (A) a volumetric 3-dimensionalcomputed tomography (CT) image and in (B) CT angiographyleft anterior oblique and (C) transverse views.

performed through the contralateral femoral artery before the

device was released (Fig 2, B) demonstrated good seal of thedefect, and the device was released from the delivery cable. AnAngio-Seal closure device (St. Jude Medical, St Paul, Minn) was

Fig 2. Conventional fluoroscopic angiographic views are shown(A) before deployment and (B) after deployment of the secondAmplatzer device.

used to close the femoral artery puncture sites.

JOURNAL OF VASCULAR SURGERYJuly 2010198 Hussain et al

A CT scan performed before discharge on postoperative day 3to assess for success of the procedure revealed a well-sealed entrypoint of the pseudoaneurysm (Fig 3).

DISCUSSION

Our case demonstrates the feasibility of repeated endo-vascular closure of aortic pseudoaneurysms. Amplatzer de-vices are increasingly used for transcatheter treatment ofcongenital and acquired structural heart disease. Currentusage includes atrial and ventricular septal defects, patentductal arteriosus, patent foramen ovale, vascular malforma-tions, and vascular pseudoaneurysms. Potential future uti-lization of different types of Amplatzer devices includetreatment of some types of endoleaks and pseudoaneu-rysm development after endograft implantations in tho-racic and abdominal aortic aneurysms. These are techni-

Fig 3. Computed tomography (CT) images after deplodevices and obliteration of flow into the new pseudoanoblique view; and (C) CT angiogram transverse view.

cally feasible and have favorable patient acceptance.

Although there is no known long-term comparison ofopen vs transcatheter techniques in different situations,recurrence and hence an increased number of proceduresmay be a concern with transcatheter procedures. Ongo-ing follow-up of reported series may help answer thesequestions.

REFERENCES1. Mudler EJ, Bockel H, Maas J. Morbidity and mortality of open recon-

structive surgery of noninfected false aneurysm detected long after aorticprosthetic reconstruction. Arch Surg 1998;133:45-9.

2. Kanani RS, Neilan TG, Palacio I, Garasic J. Novel use of the Amplatzerseptal occluder device in the percutaneous closure of ascending aorticpseudoaneurysms: a case series. Catheter Cardiovas Interv 2007;69:146-53.

3. Hussain J, Strumpf R, Wheatley G, Diethrich E. Percutaneous closure ofaortic pseudoaneurysm by Amplatzer occluder device-case series of sixpatients. Catheter Cardiovasc Interv 2009;73:521-9.

t of the second Amplatzer device show both Amplatzerm. A, volumetric view; (B) CT angiogram left anterior

ymeneurys

Submitted Jan 14, 2010; accepted Feb 6, 2010.